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i <br /> INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY REPORT FORM ,JAN <br /> r ENTAL HEALTH <br /> Facility Namer-L 7L ��;i �_{;,�Y LC�a;C�? ce Tank P S14FRMT/sEWA t <br /> i <br /> Facility Address: �700/ <br /> Telephone : ?4)�2 ,t T 3 --26„p/ <br /> Person Filing <br /> Report 'T.-. '��c <br /> I hereby certify under penalty of perjury that all inventory variations for <br /> the above mentioned facility were within the allowable limits for this <br /> quarter. (No in Column 13 of the inventory Reconciliation Sheet) <br /> E] Inventory variations exceeded the allowable limits for this quarter. I <br /> hereby certify under penalty of perjury that the source for the variation <br /> was not due to an unauthorized (leak) release. (Yes in Column 13 of the <br /> Inventory Reconciliation Sheet) <br /> List date, tank 1, and amount for all variations that exceeded the <br /> allowable limits. <br /> Date Tank If Amount <br /> 1. <br /> 2. <br /> 3. <br /> 4. <br /> 5. <br /> Additional dates/amounts shall be continued on a separate sheet of <br /> paper and attached. <br /> If the source of the variation which. exceeded allowable limits was due to <br /> a leak the incident shall be reported to S .J .L .H . D . Environmental Health <br /> Within 24 hours and an unauthorized release report submitted. <br /> The quarterly summary report shall be submitted within 15 days of the end of each <br /> quarter. <br /> Quarter I - January --) March <br /> / (7 Qaarter 2 - April --> June <br /> a Quarter 3 July Se tember <br /> Quarter 4 - October --> December <br /> Send to: SAN JOAQU N ( CAL HEALTH DIS'TRIC'T' <br /> 1601 E . Har_el [on , P . 0 - Box 2009 <br /> Stockton , CA IJ5201 466-6781 <br /> U(;T 40 10/ 86 <br />